Search “things they don’t tell you about pregnancy” on TikTok and a slew of videos pop up. New parents, shock evident in their voices, and people on their second or third child hoping to educate others, describe unexpected bodily changes—everything from chronic nose bleeds to rapid hair and nail growth. How could no one tell them this would happen?

While having a baby can be an exciting and transformative experience, for many, it also evokes understandable concern. The medicalization of pregnancy and childbirth in the Western world, moved deliveries, 98.4% to be exact, out of homes and communities and into hospitals, according to a 2017 study.

With the clinic curtain tightly drawn, pregnant people don’t know what to expect, left to navigate decisions about prenatal care, epidurals and labor–inducing drugs, and postpartum healing in a complex and often frustrating healthcare system. No wonder @girlwiththelist1 has hundreds of reasons not to have children stored in her notes app. 

“We lack real information about birth as a culture. Birth happens behind closed doors. People don't know very much about birth until they start thinking about it in pregnancy,” says Brittany Sharpe McCollum, founder of Blossoming Bellies Wholistic Birth Services

Photo courtesy of Brittany Sharpe McCollum

Helping to rewrite the predominant narrative are Sharpe McCollum and other doulas: trained, non–medical professionals who provide physical, emotional, and informational support during the birthing process, as well as throughout the prenatal and postpartum periods. “I've heard [doulas] likened to Sherpas. If you were going to climb Mount Everest for the first time, you certainly wouldn't go by yourself, you'd hire a guide,” says Christine Golcher of Christine’s Care & Compassion.

When pregnancy becomes literal horror, it’s time for a change. Doulas are here to take some of the fear and confusion out of childbirth, making sure the voices of birthing individuals are heard in the laboring room. Better health outcomes for both parents and their babies is proof their methods work, regardless of how someone chooses to deliver.

It’s never too late to hire a doula, but practitioners typically like to start building relationships with their client early in the pregnancy, over the course of several sessions with the pregnant person and their partner, if they have one. Prenatal visits are an opportunity for doulas to make sure their client knows their options, help them work through their hopes, fears, and concerns, and establish birth preferences. 

The doula community collectively supplies a variety of pregnancy–related services, with some operating more specialized practices than others. Birth doulas attend labor and delivery, and offer words of encouragement, guidance with position changes to optimize comfort, and reminders to eat and drink. It’s not their place to tell a client what to do or communicate with healthcare providers on their behalf. Instead, doulas encourage birthing individuals to advocate for themselves by affirming their right to ask questions and actively participate in the trajectory of their delivery experience.

Postpartum, most birth doulas follow up with their clients at least once to answer questions about infant care and connect them with outside resources, such as lactation consultants and pelvic floor physical therapy. Professionals who lean towards exclusively postpartum services, in addition to continued emotional support, help new parents with body care, meal preparation, and laundry—seemingly menial tasks that can feel insurmountable with a newborn in the picture. “[Postpartum doulas] care for the baby while Mom is doing something that she wants or needs to do like sleep, shower, and have a meal, knowing that [their baby] is in good hands,” says Cynthia Hillocks, a birth and postpartum doula with the Philly Doula Co–Op

PDC doulas contract their services independently, but benefit from membership in a close–knit network of birth professionals. If a doula isn’t available when their client goes into labor (maybe they can’t find childcare on short notice), they can call another Co–Op representative to take their place and ensure the birthing person has the support they need. In addition to birth and postpartum doulas, several PDC practitioners are therapists and yoga instructors, striving to achieve a truly holistic approach to health and wellness. Can we call them the best kind of all–in–one?

Hillocks incorporates aspects of traditional midwifery in her doula care, skills she acquired from studying with Latina midwives in Mexico. Practices like postpartum massage, bathing, and belly binding, considered unconventional within the Western biomedical framework, are more common among doulas and other alternative birth professionals. 

In the United States, midwives are clinically trained, often registered nurses, and employ a holistic approach to childbirth designed to avoid medical interventions and promote natural delivery. Some hospitals, such as Penn Medicine, give pregnant people the opportunity to choose between receiving care from an OB–GYN or a nurse midwife. However, smaller institutions are less likely to have midwives on staff, meaning doulas play a particularly important role in helping clients advocate for their preferred birth experience. “[Doulas] are more focused on the birthing person who can get overlooked when it's all about the [health of the] baby,” says Nia Coaxum Morgan, who runs Birth With Purpose Doula Services.

Photo courtesy of Nia Coaxum

Doulas may not be medical professionals, but that doesn’t mean their work isn’t evidence–based. It’s a mistake to assume they’re a bunch of hippies who spontaneously decided to take up a career in pregnancy and birth. Sharpe McCollum teaches workshops approved by the Pennsylvania Board of Nursing for clinical and non–clinical providers. Topics include labor physiology and pelvic biomechanics, the science of how the pelvic bones shift during childbirth, which informs positioning to promote progress during labor and decrease rates of medical intervention. She also runs education initiatives with a “focus on how to utilize movement in unmedicated births and modified movement for births with epidurals.”

A mixture of formal education and learned experience guides most doulas. One of the more popular courses is offered by DONA International, which is the route Golcher chose to take. Coaxum Morgan notes that she doesn’t “consider [herself] any better or more educated than someone who might not be certified,” since doulas can be trained without receiving an official certification. In many cases, the difference comes down to completing a few extra assignments, meaning financial barriers are a mediating factor.

While curriculum is certainly valuable, particularly for doulas who work in hospitals where certification is usually required, “you can read all the books in the world on prenatal and postpartum support, but you really do have to be able to put it into action,” says Coaxum Morgan. Experienced doulas learn to read the signs of labor and delivery, and perhaps more importantly, how to negotiate medical spaces that prioritize efficiency over the comfort of the birthing person. 

Doulas aren’t trying to deny the major public health benefits accrued through the development of hospitals. They’re reformers shedding light on the way medical education teaches providers to “look at pregnancy and birth as a condition that needs to be managed, compared to a natural physiological process. Of course, there's always those few outliers where extra care is needed, but for the most part, if you're having a healthy, low–risk pregnancy, all the interventions that the hospital often provides and might try to pressure you into aren't necessary,” says Coaxum Morgan.

A 2017 study of over 15,000 pregnant people found that doula–assisted participants were significantly more likely to have a spontaneous vaginal birth and shorter labors, and less likely to have an instrumental or cesarean birth and use pain medication. Research also indicates doulas improve birth outcomes: the likelihood of having a low birth weight baby decreases fourfold, and birthing individuals are two times less likely to suffer complications involving themselves or their baby.

As maternal mortality rates continue to worsen in the United States, far surpassing other high–income countries, doulas provide life–saving care. Almost half of new parents report suffering some form of birth trauma, which Sharpe McCollum calls a “lowball estimate.” She also emphasizes the lasting effects of adverse events during labor and delivery, damaging the ability for birthing people to bond with their baby and their relationship with their body. The results of one study found that childbirth–related PTSD is associated with lower maternal–infant bonding scores. 

Racial disparities in maternal mortality statistics are striking—Black birthing individuals are three times more likely to die from a pregnancy–related cause than their white counterparts. Both Hillocks and Coaxum Morgan pursued careers as doulas in an effort to directly address alarming inequities. “When you're a Black person or a person of another minority, these providers often have implicit biases,” says Coaxum Morgan. “There are stereotypes of you when you come into the room, which definitely all play a role in the care that you'll receive.” 

She adds that “doulas play a great role in making sure that their clients experience birth with dignity and autonomy, and that they're informed fully throughout the process.” This empowers pregnant people and leaves them feeling more satisfied with their childbirth experience.

Even the wording a healthcare provider uses to present basic medical information can make a difference in the atmosphere of the laboring room. “When something is framed in a way that makes somebody's confidence in their ability to give birth go down … it plants the seed of doubt in their mind,” says Sharpe McCollum. For example, an OB–GYN tells their patient “you’re only X centimeters dilated”—in a situation as challenging and vulnerable as childbirth, doulas recognize that language matters.  

Some people opt for a home birth or delivery in a designated birthing center, which specializes in unmedicated childbirth. Golcher describes the birthing center environment as a “beautiful, comfortable, relaxing bedroom … dim lights, quiet, very different from the hospital.” Most also have tubs to accommodate those who prefer a water birth. If a rare emergency does occur, experienced doulas and midwives know when hospital–level care is required. 

That’s not to say pregnant people can’t achieve their desired birth plan in the hospital setting, particularly with the support of a doula. Golcher remembers one client, an avid marathon runner, who knew she wanted to go the natural route and read several books on childbirth to ensure she had the tools to communicate effectively with her OB–GYN. She stood for most of her labor and delivered her baby upright, letting gravity do its work. “I could tell watching the doctor, it was a very new experience for him, but I gave him a lot of credit. He respected her wishes … She got the birth she wanted, and it was because she was very well prepared and she knew how to advocate for herself,” says Golcher. 

Unfortunately, doula care isn’t always accessible. In many states, including Pennsylvania, insurance doesn’t cover the cost of hiring a birth or postpartum doula, introducing a significant financial barrier. There are talks of expanding Medicaid to doula services, but even then some are left having to pay out of pocket. “A lot of times when people think of access, they're thinking of someone with extremely limited means. That's not always the case. It can be a two–parent household with a fairly good income, but you might not have an extra $1,200 to pay for doula support,” says Coaxum Morgan.

Sharpe McCollum is acutely aware of financial concerns, and offers expecting families scholarships as well as waivers for her professional workshops to BIPOC birth practitioners, no questions asked. She also has free webinars, which in combination amount to a “pretty solid education.”

Community doulas are another option—practitioners with strong personal connections to the regions they serve, who often connect clients with resources related to housing, food insecurity, and intimate partner violence. Pregnant people can sign up to be matched with a community doula free of charge through organizations like the Maternity Care Coalition, based in Philadelphia. Hillocks got her start as a community doula in southern New Jersey and Coaxum Morgan continues to volunteer her support through MCC. 

Balancing the provision of much–needed care with the recognition that doulas are people deserving of compensation is a difficult task. “It’s work I do to support my family. I do rely on the income, but at the same time it's childbirth, which is something that everybody deserves to have a positive experience with,” says Sharpe McCollum.

Doulas are on call for clients a month at a time, two weeks before the estimated due date and up to two weeks after, and have to be prepared to put their own life aside when labor begins, sometimes for 24 hours or more. It’s exhausting. Golcher is in the process of transitioning from running her business alone, to hiring doulas to work for her after realizing she needed to listen to her body and slow down. 

Coaxum Morgan knows doulas who refuse to support hospital births anymore because of the poor treatment themselves and their clients repeatedly face within the medical system. To find a way to continue practicing and providing life–saving care after losing a birthing individual or baby requires unbelievable strength and resilience. A difficult birth where the baby didn’t survive still weighs heavily on Hillocks. 

The success stories keep doulas going—those they support through an empowering birth experience, foregrounding the agency of the birthing person. “If [an intervention] is being suggested, it's not always framed as if it's a suggestion. I think a lot of people don't realize that saying 'no' is even an option,” says Sharpe McCollum. Doulas teach their clients to ask questions and make evidence–based decisions, but ultimately prioritize their own comfort. 

Sharpe McCollum, Coaxum Morgan, Golcher, and Hillocks all anticipate the profession continuing to expand in the future. As more people are educated on the benefits of doula support, proliferated in the media by increasing numbers of celebrities pursuing alternative birth services, Sharpe McCollum emphasizes an all–inclusive approach. Whether a birthing individual prefers a vaginal delivery or C–section, epidural or no epidural, doulas are a valuable resource. Golcher quotes DONA International when she says: “A doula for every person who wants one.”